Adult ADHD - Form

No Waiting Lists

Private ADHD

Assessement Enquiry Form

Adult ADHD Patient Journey

Adult ADHD: NHS

Patient Details

First Name (required)

Last Name (required)

Date of Birth (required)

Contact number (required)

Email Address (required)

Address (required)
Please enter your full address along with postal code

GP Details

GP's First Name (required)

GP's Last Name (required)

GP Contact number (required)

GP Email Address (required)

GP Address (required)
Please enter the GPs Practice & full address along with postal code

Clinical Information

Presenting Symptoms / Concerns: (required)

Relevant Medical History: (required)

Current Medication: (required)

Past Psychiatric / ADHD Assessments: (required)

ASRS score

(Adult ADHD Self-Report Scale - please click here to complete)

Part A Score (out of 6): (required)

Part B Score (out of 12): (required)

Total Score (out of 18): (required)

Service Preferences

Preferred Mode of Assessment (please tick): (required) Face-to-Face ConsultationOnline / Video Consultation

Consent

I confirm that the patient has given consent for this referral and for their clinical information to be shared with Elixir Medics for the purpose of ADHD assessment and treatment.I confirm that the patient consents to Elixir Medics sharing relevant clinical information with their GP for safe and coordinated care.

GP Signature (required)
Print full name as form of digital signature

Date (required)
This will be added to your digital signature

Purpose of Data Sharing

As part of your treatment or healthcare management, we may need to share your personal and medical information with authorized third parties. These may include healthcare providers, insurers, researchers, or other organizations involved in your care. This data will only be used for specific, clearly defined purposes such as improving care, research, or facilitating communication between healthcare professionals.

Please read the information below and indicate your consent.

Types of Data That May Be Shared

Personal Identifiable Information (PII): Name, contact details, date of birth, etc.

Medical Records: Diagnosis, treatment plans, medical history, prescriptions, laboratory test results, imaging data, etc.

Health Insurance Information: Policy details, coverage, billing information, etc.

Other Relevant Information: Notes from healthcare providers, case discussions, etc.

Possible Parties with Whom Data May Be Shared

We may share your data with the following organizations, depending on the need and purpose:

Healthcare Providers: Doctors, specialists, clinics, hospitals, labs, etc.

Insurance Companies: For billing, claim processing, and policy management.

Medical Researchers: In anonymized or de-identified form for clinical studies or trials.

Health Information Exchanges (HIEs): For coordinating care across multiple providers.

Other Entities: As required by law or for the purposes of improving healthcare services.

How Your Data Will Be Protected

We are committed to safeguarding your personal and medical information. We will take all reasonable steps to ensure that your data is handled securely and in compliance with applicable laws and regulations, GDPR.

We will also ensure that any third parties who receive your data comply with privacy and security standards.

Your Rights

You have the following rights regarding your data:

Access: You can request to view the data we have collected about you.

Correction: You can request to correct any inaccuracies in your data.

Withdrawal of Consent: You can withdraw your consent at any time, though this may impact your care or services provided.

Questions/Concerns: You can contact us if you have any questions or concerns about how your data is being used or shared.

Adult ADHD - Form

No Waiting Lists

Private ADHD

Assessement Enquiry Form

Purpose of Data Sharing

Types of Data That May Be Shared

Possible Parties with Whom Data May Be Shared

How Your Data Will Be Protected

Your Rights

Contact us to make an enquiry or for more information